Kitamura Hiroaki, Fujioka Shuichi, Hata Taigo, Misawa Takeyuki, Yanaga Katsuhiko
Department of Surgery The Jikei University Kashiwa Hospital Chiba Japan.
Department of Surgery The Jikei University School of Medicine Tokyo Japan.
Ann Gastroenterol Surg. 2019 Nov 11;4(2):170-174. doi: 10.1002/ags3.12297. eCollection 2020 Mar.
Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D-line) as a feasible landmark for carrying out difficult LC. The D-line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D-line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty-two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D-line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D-line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54-290) min and 10 (range, 0-100) mL, respectively. No intra- or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.
尽管获得安全的关键视野（CVS）有助于在腹腔镜胆囊切除术（LC）期间避免血管胆管损伤，但由于技术困难，在重症胆囊炎病例中并非总能实现CVS。在此，我们将肝脏IV段及其对角线（D线）作为进行困难LC的可行标志。D线连接IV段的右背侧角和左腹侧角，并用作矢量标志，即首先在此处解剖胆囊以实现CVS而不会误认。当胆囊壁瘢痕形成严重时，沿D线转换为次全胆囊切除术也是可行的。我们将此手术命名为LC的IV段入路。连续62例困难LC（包括经皮经肝胆囊引流术[PTGBD]后计划进行的27例LC和东京指南[TG] II级胆囊炎的35例保守治疗病例）采用IV段入路进行处理。44例（71%）病例成功沿D线取出胆囊；所有这些病例在全胆囊切除术后也实现了CVS。另外18例（29%）病例因严重胆囊炎伴与周围结构的炎性粘连导致沿D线取出胆囊失败而转换为次全胆囊切除术。中位手术时间和术中失血量分别为135（范围54 - 290）分钟和10（范围0 - 100）毫升。未观察到术中或术后并发症。IV段入路对于在存在胆囊壁瘢痕的困难LC病例中实现CVS和考虑次全胆囊切除术是可行的。
